Student Incident Report Page 4
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4Student Incident Report
Attachment C: Observation Form
Student’s Name:
Date:
If the student is intoxicated, document that the student is checked every fifteen minutes. If the student is not
intoxicated, record observations every thirty minutes. Use additional forms as needed.
Upon initial entry to the sick bay/transition dorm or dorm of origin, staff will record student observations in
Table 1.
Table 1: Observation Entries
Time
Initials
Observation
Initials
Time
Observation
Staff on Duty
Time in
Time out
Staff on Duty
Time in
Time out
Staff on Duty
Time in
Time out
Staff on Duty
Time in
Time out
Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones
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